Dry Mouth, Bleeding Gums And Mouth Ulcers At The Same Time: What To Do And What To Ask Your Dentist

This article is for information only. I am not a dentist or a doctor and nothing here is a diagnosis. See a dentist or GP about any of the symptoms described.

The thing about a dry mouth is that you do not notice it as a symptom for a long time. You notice that you keep a glass of water by the bed, that crackers have become impossible, that you wake at 3 with your tongue stuck to the roof of your mouth, and you deal with each of those as its own small annoyance. It took me about 4 months, when I was on a long course of antihistamines a few years ago, to say the words “my mouth is dry” out loud to anyone, and by then I had a filling at the gum line of a tooth that had never had a problem in 40 years and gums that bled every time I brushed. The dentist looked at the tooth pain, asked what I was taking, and had the whole thing worked out in 30 seconds. I had spent 4 months on it.

So when a woman emailed me last week with a list that was so much worse than mine, and the same instinct running underneath it that she was doing something wrong, I wanted to write this down properly. She is 50. She had sepsis 9 months ago and nearly did not come home. Since then, severe dry mouth for months, big ulcers that keep coming back, gums receding and bleeding, cracks she can see at the neck of the teeth, and white patches inside her lower lip she found with her phone camera. She cleans her teeth harder than I do, electric brush, water flosser, interdental brushes every morning, and it leaves her teeth on edge for hours, so at night she just does salt water and the brush because she would not sleep otherwise. Hygienist twice a year. Dentist twice a year. Getting worse.

She is not doing anything wrong. Her mouth has stopped making enough spit, and everything else on that list is what a mouth does when that happens.

The Saliva Part

Saliva does about 6 jobs and cleaning is only 1 of them. It rinses plaque off the teeth between brushes, it cancels out the acid from food and from the bacteria in the plaque, it carries calcium and phosphate back into enamel that has started to soften, it keeps the lining of the mouth stretchy so it does not split when you yawn, and it has its own antibacterial proteins in it. Take it away for a few months and plaque sits on the teeth 20 hours a day instead of 2, the gums get sore and bleed and start pulling back, the newly exposed root surfaces go sensitive because they have no enamel on them, decay starts exactly where the gum meets the tooth, and the lining tears and ulcerates over nothing. That is her whole list, from 1 cause. Which is good news in a way, because it means the question is not 5 questions. It is 1. Why has the mouth gone dry, and can it be reversed?

What Dries A Mouth Out For Months

• Medication is the answer most of the time, and hundreds of drugs do it: blood pressure tablets, antidepressants, antihistamines like mine, bladder medicines, strong painkillers, and a fair amount of what gets given in intensive care and in the months after it.
• Sjögren’s is the immune system attacking the saliva glands themselves, it is most common in women between 40 and 60, and it is found with a blood test and by measuring how much saliva she makes in 5 minutes, which a dentist can do with a plastic cup and a stopwatch.
• Diabetes dries the mouth as well and can start quietly after a severe illness, and that is a finger prick test.
• Sepsis on its own leaves the immune system disturbed for a year or more, and nobody can say yet how much of hers is the illness and how much is the treatment.

I would put money on the medication being at least part of hers. Anyone leaving hospital after sepsis tends to leave with a bag of new prescriptions and nobody sits down and says, by the way, 3 of these will dry your mouth out. The list of what she takes is the first thing to put on the desk next week.

The Ulcers, And The White Patches

The ulcers are a slightly separate thread. Everybody gets the odd one from biting a cheek. Big ones, every few weeks, for months, are a different thing and the usual culprits are low iron, low B12, low folate, which serious illness and long antibiotic courses drain, and occasionally coeliac disease or the same autoimmune conditions. One set of blood tests from a GP covers all of it. An ulcer that has not healed in 3 weeks gets looked at, that is the rule, not waited out.

The white patches I am going to be careful about. Her photo showed white, slightly lacy marks on the inside of the lower lip with red around them. I do not know what they are and I am not going to guess in an article. The rule dentists work to is simple though: any white or red patch that is still there after 2 to 3 weeks gets examined, photographed, and if there is any doubt at all, referred on to an oral medicine clinic. Most of these turn out to be nothing much. Some are an inflammatory condition with a name and a treatment. A small number matter enormously, which is the entire reason they get looked at rather than watched. This is the first thing she should show the dentist, before anything else on the list.

The Appointment

Dental health run to a 20 minute slot and she has a 20 item life. Written list, most worrying thing first, and do not let the appointment turn into a scale and polish.

• The white patches inside the lip: look at them and photograph them, and do I need a referral.
• The dry mouth: can you measure my saliva, and should I be tested for Sjögren’s and for diabetes.
• The ulcers: should my GP be checking iron, B12 and folate.
• Here is every tablet I take since the sepsis, are any of these drying my mouth.
• Can I have the 5000 ppm fluoride toothpaste on prescription, because a dry mouth makes decay far more likely.
• Can you put fluoride varnish or a desensitiser on the exposed roots so cleaning stops hurting for hours afterwards.
• The back molar that has lost a corner, what is happening there.

If the dentist tips does the first 2 and looks at the clock, fine, take the rest to the GP the same week with the same list and say the word sepsis again. I have found that people repeat themselves less than they should in medical rooms because it feels rude. It is not rude. It is the only way anything gets written down.

Cleaning A Mouth That Hurts

When To Floss

Her instinct to skip the flossing at night because it hurts is completely understandable and it is the wrong call, and I say that as someone who did the same. Plaque left in a dry mouth overnight does more damage than plaque left in a wet one during the day, because there is no saliva to slow it down. So the interdental brushes and the flosser need to happen, but they do not need to happen at 7 in the morning on teeth that have been dry all night. Whenever the teeth are least sensitive, mid afternoon, after a meal, every second day if that is all she can manage. Something is much better than nothing and the hygienist can check she is using the right sizes, because a brush that is too big is most of the pain.

What To Use

• Sensitive toothpaste twice a day, lightest pressure the electric brush allows, soft head, and spit without rinsing afterwards so the fluoride stays put. That last one changed more for me than anything else and nobody had ever told me.
• Salt water once a day and not more, because salt dries.
• Any mouthwash with alcohol in it goes in the bin, it strips what little moisture is there and it stings the ulcers.
• A dry mouth gel or spray during the day, Biotène is the one most chemists stock, and at night a XyliMelt or similar disc stuck to the gum, which dissolves slowly and keeps the mouth wet through the hours when it dries the most.
• Sugar free gum between meals, and water sipped all day rather than a glass every few hours.
• Nothing spicy, acidic or sharp edged while the ulcers and the patches are active, so no crisps, no orange juice, and I am sorry about the crisps.

None of that fixes the cause. It holds the line while the blood tests come back.

If a patch changes colour or goes hard, if an ulcer is still there at 3 weeks, if the molar starts hurting on its own, she rings and asks to be seen before the routine slot, and she says why. Her feeling that all of this started with the sepsis is very likely correct, and the most useful sentence she can say next week is exactly that, followed by handing over the tablet list. I would like her to write to me again in a month. I think the answers will be in the bloods.